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General NPI Number Information
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NPI Number | 1811239338
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Entity Type | Organization
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Legal Business Name | SUSANNA RAND
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Dates
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Enumeration Date | 03/22/2013
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Last Update Date | 03/22/2013
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Provider Practice Location Address
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Address Line | 500 N MAIN ST STE 1006
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City | ROSWELL
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State | NM
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Zip | 88201-4768
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Country | US
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Telephone | 575-626-9593
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 3564
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City | ROSWELL
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State | NM
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Zip | 88202-3564
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Country | US
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Telephone | 575-626-9593
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | SUSANNA RAND
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Credential | LPCC
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Telephone | 575-626-9593
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 0151651
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License Number State | NM
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